By Jeff Szymanski, PhD
When a person with OCD tries to do something to reduce the anxiety from obsessions we call this a compulsion. The tricky thing to remember about compulsions is that they can be behaviors that you can see (hand washing) or can be done inside one’s head. In the latter case we call this a mental compulsion. Counting is an example of a mental compulsion. Other mental compulsions include mentally reviewing, praying, thought suppression, or “undoing” or “cancelling” a negative thought with a positive one, for example. There was confusion for a long time about this part of OCD. People with mental compulsions but not physical ones were called “pure obsessionals”, because it had been thought that all obsessions were mental and all compulsions were physical and could be seen. I will return to this issue in a future blog as this distinction is critical for getting the right treatment.
Another overlooked topic when compulsions are being discussed is avoidance behavior. Again, compulsions are mental or physical acts a person does to try to decrease anxiety. One thing they might do is avoid anxiety-causing situations all together. In some cases, avoidance behavior can be more debilitating than what is traditionally thought of as compulsive behavior. Therefore it is very important that therapists ask about this during an initial meeting and individuals with OCD make sure to include this when describing their symptoms.
Common compulsions include cleaning, checking, repeating, and arranging/ordering.
- Cleaning can be focused on oneself (examples: 50 hand washes per day, 90 minute shower) or on one’s environment (2-3 hours of cleaning the house every day).
- Checking compulsions include making sure that one’s environment is safe (rechecking door locks, stoves, windows) or that making sure you haven’t harmed someone by mistake. For example, a common compulsion for those with OCD is a fear of having accidently hurt someone while driving and retracing their route to check to make sure nothing happened. An often overlooked checking compulsion is reassurance seeking. In other words, checking with others repeatedly that something is okay or that everyone is safe. Remember, this is a disorder, so the reassurance seeking isn’t just a couple of questions. In the case of OCD, it is 20-30 questions (or more) about the same thing every day.
- Common repeating rituals include repeating an activity over and over again (flipping light switches on and off, going in and out of the same entrance), repetitive body movements (tapping objects a certain number of times), and doing activities in multiples (touching something three times because three is a good number).
- Examples of common arranging and ordering compulsions include spending excessive amounts of time lining things up so that they are perfectly aligned and using elaborate categorizing systems. These compulsions are typically driven by obsessions about wanting things to be perfect.
Any of these compulsions, however, can be driven by any type of obsession. Although a fear of contamination typically results in compulsive cleaning, compulsive cleaning could be driven by scrupulous (religious or moral) obsessions as well.
Keep in mind that the above list does not include every kind of obsession and compulsion. These are just some examples. In addition, I did not cover hoarding in this list as hoarding is increasingly being thought of as possibly something different than (but overlapping with) OCD. There is an excellent discussion of this at www.helpforhoarding.org written by Randy Frost, one of the leading researchers and therapists in the area of hoarding.
The final issue I wanted to tackle related to compulsions is how to tell the difference between compulsive behavior from impulsive behavior. Again, this distinction isn’t just academic as there are implications for treatment. Compulsive and impulsive behaviors are both characterized by a failure to resist engaging in repetitive behaviors and distractibility. However, compulsive behavior is aimed at decreasing distress whereas impulsive behavior is directed toward increasing immediate pleasure, arousal, or excitement. Those with compulsive behavior overestimate the chance of harm or danger and are afraid of taking risks. Those with impulsive behavior underestimate the chance of harm to themselves and others and are risk takers. As such, it is more accurate to say someone has difficulty with impulsive shopping, impulsive gambling, impulsive sexual behavior, impulsive eating, etc.
In summary, compulsions can be seen or can be inside someone’s head, avoidance is often overlooked but extremely important to consider and telling the difference between compulsive and impulsive behavior can make the difference between getting effective treatment and not.